Guide for rapid assessment of interactions between HIV programmes and health systems

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Guide for rapid assessment of

interactions between HIV programmes and health systems

World Health Organization

Regional Office for the Eastern Mediterranean P.O. Box 7608, Nasr City 11371

Cairo, Egypt www.emro.who.int

This publication provides guidance and a tool for assessing interactions of HIV programmes with national health systems. The purpose of such assessment is to explore to what degree and how HIV programme functions are integrated into national health systems and to study the positive and negative aspects of these interactions in view of HIV programme and health system performance. Assessment aims to promote thinking and discussion on these issues among key stakeholders, namely government, private sector and civil society leaders involved in public health, and representatives of beneficiaries. The results should inform national planning and the preparation of grant proposals for HIV programme and health systems strengthening.

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Guide for rapid assessment of interactions between HIV programmes and health

systems

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WHO Library Cataloguing in Publication Data

World Health Organization. Regional Office for the Eastern Mediterranean

Guide for rapid assessment of interactions between HIV programmes and health systems / World Health Organization. Regional Office for the Eastern Mediterranean

p.

ISBN: 978-92-9021-965-1

1. HIV Infections - prevention and control 2. Programme Evaluation 3. Systems Integration 4. HIV Infections - economics 5. Delivery of Health Care, Integrated I. Title II. Regional Office for the Eastern Mediterranean

(NLM Classification: WC 503)

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

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Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: [email protected]). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address; email: [email protected].

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Acknowledgements

This guide is the product of collaboration between the World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt; Gephyra International Health Consultancy, Amsterdam, the Netherlands; Evaplan GmbH, Heidelberg, Germany; and the American University of Beirut (AUB), Lebanon.

The final version was prepared by Thyra de Jongh (Gephyra IHC) and Gabriele Riedner (WHO Regional Office for the Eastern Mediterranean) with input from Hamida Khattabi (WHO Regional Office for the Eastern Mediterranean) and Jos Perriens (WHO headquarters). The guide builds on previous versions developed by a group of experts including Michael Marx, Helen Pythrech, Siegrid Tautz and Peter Campbell (EvaPlan GmbH), Shadi Saleh and Jocelyn Dejong (AUB) and Belgacem Sabri, Sameen Siddiqi, Veronique Bortolotti and Gabriele Riedner (WHO Regional Office for the Eastern Mediterranean).

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Introduction

The Eastern Mediterranean Region of the World Health Organization and the Middle East and North Africa Region of the Joint United Nations Programme on HIV/AIDS (EMR/MENA) are characterized by low levels of HIV prevalence in the general population and increasing evidence of concentration of risk in specific populations including injecting drug users, sex workers and men who have sex with men. Stigma associated with HIV and risk behaviours is high. The income levels of countries in the Region and the maturity and capacity of health systems vary a lot and there are many different ways in which HIV programmes interact with national health systems.

In order to gain better insight into the relationships between HIV programmes and health systems, in particular in terms of integration of HIV programmes into general health systems, in different country contexts in the Region, the WHO Regional Office of the Eastern Mediterranean launched in 2009 a project entitled “Achieving coverage, quality and sustainability in the context of existing health systems”. The subject of the project is the interaction between, and integration of, HIV programmes and interventions into health systems. While national HIV responses engage a wide range of sectors this project focuses on the health sector. A similar approach could be applied to other disease programmes in the health sector and to HIV programs of other sectors. The approach is also applicable beyond the EMR/MENA Region, in particular in countries with low-level/concentrated epidemics.

As a first step, the project undertook four country case studies to explore the degree to which existing health systems integrate HIV/AIDS programmes and interventions. This has involved the development of a conceptual framework for the assessment of the current status of integration and the analysis of determinants and effects of integration. An initial assessment instrument consisting mainly of semi-structured interview questions was applied in four countries: Islamic Republic of Iran, Morocco, Sudan¹ and Yemen.

The results of these studies provided a snapshot of the current status of integration in these four countries.

However, the case studies had limitations in terms of providing insight into stakeholders’ views on the determinants of integration and its effects. Based on the experience of the four country case studies and recommendations made by national AIDS programme managers in the Eastern Mediterranean Region at the 19th regional meeting in 2010, a further evolution of the assessment methodology and tool took place to include more explicitly two themes:

1) stakeholder perception with regard to enabling and constraining factors of the health system for HIV programme delivery; and

2) the awareness and comprehension of effects of the HIV programme on the performance of the health system.

Besides elucidating stakeholders’ viewpoints, the methodology is designed to trigger relevant reflection and discussion among decision-makers and their advisers in ministries of health, WHO and other partners. The methodology was piloted in Egypt between April and June 2011. A number of adaptations were subsequently made which are incorporated in this document.

1 The objectives of these country case studies were: to assess and describe the situation regarding integration of HIV programmes and services into the existing health system; to explore and describe by whom and based on what considerations the decisions are made regarding the way how health sector HIV programmes are implemented including decisions on integration versus non-integration; and to explore and describe views of key stakeholders regarding the positive and negative effects of integration or non-integration in terms of facilitating increased access to quality interventions/services and their sustainability.

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Figure 1. Conceptual framework for rapid assessment

HIV incidence and mortality Other health outcomes

Health system

HIV programme

Degree of integration and interaction of health system functions and HIV programme

• Governance and leadership

• Financing

• Health workforce

• Medical products and technologies

• Information

• Service delivery

Context

:



Epidemiology



Politics



Legal frameworks



Economic factors



Sociocultural factors

HIV programme performance HIV services

(e.g. antiretroviral treatment, prevention of mother-to-child transmission, HIV counselling and testing, harm reduction)

• Access and coverage (including key populations at higher risk of HIV )

• Quality

Health system performance General health services

(e.g. antenatal care, maternal and child health, tuberculosis)

• Access and coverage

• Quality

• Sustainability

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Conceptual framework

This assessment tool is based on a conceptual framework for the analysis of the interactions between HIV programmes and the general health system. The emphasis throughout is on the determinants and effects of integration of HIV programme functions in general health system functions.

The framework is designed around the six health system functions (governance and leadership; financing;

health workforce; medical products and technologies; information; service delivery) that determine, together with broader contextual factors, the coverage, quality and sustainability of health interventions and ultimately the achievement of improved health outcomes. HIV programme functions are integrated to varying degrees into general health system functions and sometimes develop separate so-called “parallel” systems with potential positive and negative repercussions on the general health system’s and their own functionality (see Figure 1).

Purpose of the assessment

This assessment is designed to explore how the HIV programmes interact with the national health system and, in particular, how HIV programme functions are integrated into national health systems. Furthermore, it examines the factors that have influenced the degree of integration, including the ability of health systems to accommodate HIV programme needs. In this respect the assessment may also reveal health system strengthening needs. Lastly, the positive and negative aspects of the interactions between the HIV programme and the health system are studied in view of HIV programme and health system performance.

The assessment aims to promote thinking and discussion on the above issues among a specific group of stakeholders, namely government, private sector and civil society leaders involved in public health, and representatives of beneficiaries. The results should inform the preparation of grant proposals for HIV/AIDS and health systems strengthening, national planning for HIV/AIDS and overall national health planning.

Consideration should thus be given to conducting the assessment as part of the situation analysis in those processes.

While health is a public good that is the concern of many sectors, the assessment focuses on the health sector², in order to limit it to a manageable scope.

Accordingly, the objectives of the assessment are:

• to assess and describe the current situation regarding integration of HIV programmes and services into a country’s health system;

• to explore the views of stakeholders on:

• the ability of the existing health system to fulfil the requirements for effective HIV programme performance;

• how the existing capacity of the system influences decision-making on integration of HIV programme functions;

• the positive and negative effects of the current level of integration of HIV programmes/interventions on the performance of the health system and of the HIV programme;

• positive and negative effects of the current level of integration on the achievement of coverage, quality and sustainability of HIV interventions.

• to initiate discussion on positive and negative aspects of the current interactions between the HIV programme and the health system and explore ways for improvement.

• to formulate strategies and plans to improve the efficiency of HIV/AIDS interventions implemented through the health system.

This assessment is designed to trigger discussion in countries on the optimal ways to implement HIV programmes in the context of an existing health system, with the aim of benefiting the performance of both

2 It should be noted here that other sectors, such as for example the education sector, are also important contributors to public health and might face similar issues regarding integration of HIV programmes.

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the HIV programme and the health system. This should reflect on how to achieve the optimal degree of integration of HIV programmes in a country’s health system context and on how to leverage these interactions to achieve strengthening of the system. These discussions should, in turn, inform the design and implementation of ongoing and planned HIV service delivery in order to achieve improved overall results.

Overview of rapid assessment methodology

The aim of the rapid assessment is not to gain a complete picture of the interactions between the health system and the HIV programme, but rather to develop an understanding of the most relevant aspects that impede or enhance HIV programme and/or overall health system performance, to promote discussion around these, and to formulate strategies to improve both. The assessment thus focuses on a few chosen thematic areas. The methodology includes a review of documents, key informant interviews, and a workshop for validation of the findings.

Key informants

It is suggested that the methodology be targeted primarily at a limited number of leaders from government, private sector, civil society and international development partners involved in the planning, design, implementation and funding of HIV-related policies and programmes and representatives of beneficiaries. In addition, the opinion of service providers will be sought by interviews with health care workers at the facility level. For reasons of patient confidentiality and the need for ethical clearance, it is not possible within the scope of this assessment to conduct interviews directly with the recipients of services. Instead, their views will be sought through interviews with representatives of consumer organizations (e.g. associations of people living with HIV).

Assessment instrument

The assessment instrument focuses on several key areas of interest, each of which is dealt with in detail. It consists of a guide for key informant interviews that includes questions and prompts, arranged into thematic modules according to health systems functions. Each module is preceded by the requirement to draw an organizational diagram in order to gain an overview of the relation between the health system and the HIV programme, without adding to the length of the interviews. It is envisaged that these diagrams are drawn by the lead expert beforehand and will be validated and elaborated on by the interviewees.

Assessment process

The following eight steps are proposed for a national level exercise facilitated by WHO Regional Office for the Eastern Mediterranean. This process can, however, be adapted for use at lower levels in the health system (provincial, district), or within a health service organization, in which case the roles of experts and contributing organizations would require adaptation.

Establishment of a steering committee

A steering committee, comprising senior managers from within the government (Ministry of Health) and leaders representing nongovernmental organizations and development partners, is assembled by the relevant authority (e.g. Minister of Health, Chair of National AIDS Committee). Committee members should be involved in HIV and reproductive health programmes and/or in activities cutting across the health system and should be interested in guiding the assessment within the country context. This broad representation will help ensure that linkages between the various systems are considered in sufficient depth.

Appointment of a lead expert and assessment working group

A lead international expert should be appointed to manage and implement the assessment. This lead expert will work in close collaboration with a consultant from the assessment country who is more closely familiar with the local context. Both the lead expert and the national consultant must have a good understanding of 8

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HIV programmes and their interactions with and integration into health systems. Two staff members from the Ministry of Health will be assisting them in this work; one representing the National AIDS Programme (or equivalent) and one representing a department of the Ministry of Health whose activities cut across the health system. Together, the consultants and Ministry of Health staff will form the Assessment Working Group (AWG). This group will take responsibility for adapting and implementing the rapid assessment instrument. Moreover, this group will be involved in selection of key informants, developing draft versions of organizational charts, and in planning the analysis of findings and in report writing.

Selection of key informants

A number of selected health leaders with sufficient understanding of the health system and the HIV programme need to be interviewed. These should be drawn from the Ministry of Health, the National AIDS Programme/Committee, other relevant government bodies (e.g. regulatory authority, Ministry of Finance etc.), the Global Fund to Fight AIDS, Tuberculosis and Malaria Country Coordination Mechanism (if present), United Nations agencies (e.g. United Nations Joint Programme on HIV/AIDS, World Health Organization, World Bank, United Nations Children's Fund) and other organizations such as influential large donors (Global Fund, President’s Emergency Plan for AIDS Relief (PEPFAR), bilaterals), associations of medical professionals, nongovernmental organizations providing HIV and health services and civil society organizations that represent and/or are advocates of people living with HIV. In addition, a limited number of health facility managers and health care providers will be interviewed on the issues within their area of expertise and responsibilities. The total number of informants will likely be in the range of 35–45 persons. A suggested list of informants for each of the thematic areas of the assessment is provided in Annex 1.

Desk review

The national consultant, with guidance from the lead expert and assistance from the other members of the assessment working group, will conduct a desk review for Phase 1 of the assessment. This involves the review of relevant documents, such as recent official policy documents, strategic plans, grant applications, and evaluation reports. A list of documents that are recommended for inclusion on the desk review, and a general outline, are provided in Annex 2. The review will aid in drawing up the six organizational diagrams prior to the interview process.

Interviews

Interviews with key informants are guided by the semi-structured interview questions presented in this assessment instrument (in English and Arabic). They will be conducted jointly by the lead expert and the national consultant. Simultaneous translation might be needed depending on whether the lead consultant speaks the local language.

Preliminary data analysis, presentation and discussion

The lead expert, with support from the national consultant, carries out a preliminary analysis of the primary data. The findings from this preliminary analysis will then be presented to the steering committee for initial validation and for identification of issues that require more clarification and in-depth analysis. The lead expert and national consultant will then conduct additional analysis and prepare a draft report. The findings and the draft report will be shared with a group of stakeholders consisting of HIV and health systems leaders and, as appropriate, client representatives during a synthesis and validation workshop. During the workshop further discussion of the issues can take place to validate the findings and to stimulate the development of more ideas and inspire motivation for improvement. The objectives of this workshop thus are: 1) to validate the findings; 2) to gather more opinions around the interactions between the HIV programme and the health system and, in particular, the integration of the HIV programme; and 3) to discuss recommendations to address obstacles to beneficial integration and to strengthen synergies between the HIV programme and health system.

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Final data analysis and reporting

The lead expert, with support from the national consultant, finalizes the analysis and collates the findings and recommendations into a draft of the final report. The draft report is presented to the steering committee and WHO. Their feedback is subsequently incorporated into the final report. The steering committee may agree at that point on key recommendations to be implemented, a follow-up mechanism and concrete next steps to be taken.

Dissemination of findings and next steps

The steering committee will decide on how the findings may be presented to a larger group, perhaps as part of a regular HIV programme review meeting, and the written report distributed to interested/relevant individuals/organizations. Also, the WHO Regional Office will compile the final reports from participating countries for analysis of the wider situation in the Region and to facilitate higher-level discussion of the issues.

Summary of assessment process

• A lead expert is contracted.

• The Ministry of Health of the assessment country nominates national members of the steering committee.

• The steering committee nominates members of the assessment working group.

• The national consultant arranges a first meeting of the steering committee and assessment working group to orient the steering committee on the conceptual framework and the assessment methodology;

WHO and/or the lead expert present the conceptual framework and methodology at this meeting.

• The steering committee reviews the objectives and processes of the assessment and provides input on the selection of key informant.

• The assessment working group reviews the assessment instrument to ensure it is comprehensive and appropriate to the country context.

• The national consultant collects relevant background documents and literature and collates the information into a desk review report.

• The assessment working group sends letters of request for cooperation to the initial group of key informants and schedules interview appointments; it is crucial that key informants are well informed before the interview about the process and objectives of the assessment.

• The lead expert and national consultant conduct the interviews.

• The lead expert, with assistance from the national consultant, conducts preliminary analysis of the data collected.

• The assessment working group and lead expert present the preliminary findings to the Steering Committee for discussion, validation and identification of issues that require clarification and more in depth analysis.

• The assessment working group organizes a synthesis and validation workshop with a selected group of key stakeholders during which findings, implications and recommendations are discussed.

• The lead expert, with support from the national consultant, prepares a draft of the final report.

• The assessment working group and lead expert present the draft of the final report to the steering committee. Key recommendations are identified and the steering committee may agree on a follow-up mechanism for their implementation and determine concrete next steps, including the wider dissemination of the final report.

• The lead expert finalizes the report.

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Definitions

For the purposes of this rapid assessment instrument, the following terms are defined:

Health sector: The health sector consists of organized public and private health services (including health promotion, disease prevention, diagnostic, treatment and care services), the policies and activities of health departments and ministries, health-related nongovernmental organizations and community groups, and professional associations.³

Health system: A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.⁴

Health service delivery: Delivery of services, be they health promotion, prevention, treatment or rehabilitation, delivered in the home, the community, the workplace, or in health facilities.

Stakeholder: Any party to a transaction that has particular interests in its outcome.

Policy: Officially recognized plans or strategy or regulations that explain an organization’s intention to influence and determine decisions, actions, and other matters.

(HIV) Programme integration: The reliance on routine health system structures, mechanisms and/or processes to execute a particular function of the (HIV) programme. Programmes may vary both in their level and nature of integration. The level of integration can be viewed as varying from complete separation (‘no integration’), to basic coordination (‘limited integration’), to active collaboration (‘moderate integration’), to complete sharing of structures, mechanisms or processes (‘high integration’). The nature of integration is associated with the individual structures, mechanisms and/or processes under consideration.

Coverage (of HIV services): Number of people reached by (HIV) health prevention, care and treatment services, usually expressed as a percentage of the estimated number of people in need of services.

Quality (of HIV services): The achievement of optimal physical and mental health through accessible, cost- effective care that is based on best evidence, is responsive to the needs and preferences of patients and populations, and is respectful of patients' personal values and beliefs.

Sustainability (of HIV programmes/interventions): Programme sustainability includes, but is not limited to, the continued commitment of funding and resources. The definition also involves the extent to which the programme continues to be operational, cohesive and developing.

Rapid assessment instrument

Phase 1: Preparation prior to interviews

In order to limit the number of questions asked of each informant and to ensure that the interviewer has a sufficient understanding of existing structures and processes to inform the interview, draft diagrams of organizational structures are to be drawn prior to the interview stage of the assessment (Table 1). This is to be done by the Assessment Working Group using available organizational charts and descriptions, as well as personal knowledge.

The diagrams are not intended to show every single detail, but rather to provide an overview of the situation that will give understanding of the functioning and extent of any linkages/integration without the need for further detailed questioning of informants. Each diagram should clearly highlight linkages between the HIV programme structures/mechanisms and the general health system structures/mechanisms. Examples of each type of chart for guidance purposes are given in Annex 3, but their format is only for demonstration purposes and other formats may be used, as appropriate.

3 Adapted from: Glossary of terms used in the “Health for All” Series No. 1–8. Geneva, World Health Organization, 1984 (Health for All Series, No 9). http://whqlibdoc.who.int/hq/1998/WHO_HPR_HEP_98.1.pdf

4 Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva, World Health Organization, 2007.

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The prepared diagrams should be brought to the interviews so that they can be used at the start of each interview to establish a common understanding between the informant and the interviewer of the relevant structures and/or processes. Informants can then be asked to review and, if necessary, revise the diagrams.

These discussions should focus on key aspects of the diagrams only and not take up more than a limited part of the allocated interview time (max. 5-10 minutes).Based on the informants’ input, as well as on more detailed analysis of the collected data, the diagrams can be further adjusted. The resulting diagrams should then be discussed with participants in the synthesis and validation workshop. Once finalized, the diagrams can be added as an annex to the report.

Table 1. Diagrams to be prepared before interviewing informants

No. Theme Description Information sources

1 Leadership and

governance

Diagram of the organizational structure of the national HIV programme and its placement in relation to other relevant organizational structures (i.e. Ministry of Health, National AIDS

Commission, Country Coordinating Mechanism, private sector, civil society, etc), clearly outlining any (formal and informal) linkages between them.

a) Documents e.g. strategic plans, grant applications, programme reports, publications.

b) Interviews with leaders from e.g. National AIDS Control Programme, National AIDS Commission, Ministry of Health, UNAIDS, country coordinating mechanism, WHO 2 Leadership

and

governance

Diagram of the HIV programme decision- making bodies/positions in relation to the decision-making bodies in the general health structures (e.g. Ministry of Health; Ministries of Finance, Education and the Interior; donor coordination mechanisms), indicating how they relate to each other hierarchically and

functionally.

b) Interviews with leaders from e.g. National AIDS Control Programme, National AIDS Commission, Ministry of Health, UNAIDS, country coordinating mechanism, WHO

3 Health financing

Flow chart showing main funding sources and financial management systems for HIV programmes in relation to the general health system financing sources and systems (include private sector and household expenditures).

b) Interviews with leaders from e.g. National AIDS Control Programme, National AIDS Commission, Ministry of Health, UNAIDS, country coordinating mechanism, WHO, PEPFAR, World Bank Multi-country HIV/AIDS Program. Also service providers.

4 Medicines and technology

Flow chart showing the systems for the procurement and supply of HIV-related drugs and commodities (i.e. ARVs, drugs for treatment of opportunistic infections, HIV test kits) in relation to the general Ministry of Health procurement and supply systems.

b) Interviews with leaders from e.g. National AIDS Control Programme, National AIDS Commission, Ministry of Health, UNAIDS, country coordinating mechanism, WHO, PEPFAR, World Bank Multi-country HIV/AIDS Program. Also service providers.

c) Available information from WHO Regional Office for the Eastern Mediterranean showing organization of procurement of medical supplies for HIV services 5 Information Chart showing the systems for data collection,

analysis and reporting for the HIV programme in relation to the general health management information systems. The chart should also include mention of the structures responsible for data analysis and reporting (both upwards and downwards).

b) Interviews with leaders from e.g. National AIDS Control Programme, National AIDS Commission, Ministry of Health, UNAIDS, country coordinating mechanism, WHO 6 Service

delivery

Organizational chart showing how HIV services (prevention, care, treatment) are delivered in relation to the health care delivery system, i.e.

what services are delivered; where (e.g. type of facility); when (e.g. dedicated clinic hours); and by whom? The chart should indicate systems for referral across services and collaboration between programmes.

a) Documents, e.g. strategic plans, grant applications, programme reports,

publications. b) Interviews with leaders from e.g. National AIDS Control Programme, National AIDS Commission, Ministry of Health, UNAIDS, country coordinating mechanism, WHO

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Phase 2: Data collection through semi-structured interviews Scheduling interviews

• The assessment working group, with input from the Steering Committee, will draw up an initial list of key informants. It is preferable that these interviews are scheduled in advance of the field visit from the lead expert, even though in practice interviews tend to be prone to last minute scheduling changes. Before scheduling interview appointments, it is important to consider the following:

• Is a letter of introduction needed? Some informants may be unwilling or unable to participate in an interview unless a formal letter of introduction has been presented in which the objectives and methodology of the assessment have been elaborated. It is often helpful if this letter of introduction is (co-)signed by a key official within the Ministry of Health or another government department to demonstrate high-level support for the assessment.

• Is formal approval from higher management needed? In some organizations approval from headquarters needs to be obtained before the informant is allowed to participate in any interview. The invitation for participating in the assessment should therefore be issued sufficiently in advance so that the informant will have time to obtain the required approval.

• Does the informant need to sign a consent form? Sometimes local or institutional regulations may require that informants sign a consent form before the interview. A sample consent form is provided in Annex 5.

• Is an interpreter necessary? It is important that informants are able to express themselves freely and, as such, they should be offered the possibility of conducting the interview in their own language. If the interviewer does not speak this language, a professional interpreter is strongly recommended. This interpreter should be sufficiently familiar with the relevant jargon and terminology. To this end the interpreter should be provided beforehand with a copy of the interview guide in both languages, as well as a list of key terms and abbreviations.

• The location and time for the interview should be chosen so as to best accommodate the informant, and should be such that the interview can take place in an undisturbed, quiet and confidential surrounding.

Offices that are shared by several people are thus not recommended as interview locations. Private offices or meeting rooms are preferred.

Before initiating the interview

Before undertaking any interviews, the interviewer(s) needs to have full understanding of the major definitions (described previously) that are being used and should understand the underlying rationale for each of the questions provided in the interview guide. The interviewer(s) have to be sufficiently familiar with the information summarized in the diagrams prepared in Phase 1. It is recommended that before commencing the interview phase, interviewers test their understanding of the methodology, their background knowledge, and interview skills in a small number (1—3) of practice interviews. Ideally, these practice interviews are conducted during a 1 day training under the guidance of someone experienced in the methodology and interview techniques. Video or audio recording of these interviews and subsequent play back can be particularly helpful during the training. It should be kept in mind that the focus of these practice interviews should be on the interview process itself (e.g. did the interviewer probe sufficiently? Did he or she ask questions in an open and non-leading way? Did the interviewer give sufficient time to respond?) and on the interviewer’s understanding of the assessment objectives and methodology (e.g. if the informant did not understand the question, was the interviewer able to explain or rephrase it?). They should, however, not focus on the content of the responses. The informant should thus ideally be someone who is directly involved in the assessment and who either would not be on the list of assessment informants or who would not object to be interviewed again.

At the start of each interview, the interviewer should introduce all the members of the assessment team present and explain what the objectives of the assessment are, what the structure of the interview (including expectations of time needed) will be, and how the information obtained will be used. Some possible guidance for this is given below:

“We are conducting an assessment entitled ‘Rapid Assessment on Interactions between HIV Programmes and Health Systems’. The assessment seeks to find out what the linkages are between HIV programmes and the health system in general and, in turn, how these linkages affect the HIV programme and health system performance. This

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information may help to improve policies, programmes and services, both in this country and across the region. We are interested in hearing your ideas and opinions on this subject. For this purpose we have developed a series of questions to guide our discussion.

In general, we are looking for as clear as possible a description of the situation and for your estimations and opinions on certain aspects of it. Wherever possible, though, we would like to know the motivation for your ideas and opinions. The information you provide us will not be made attributable to you. The interview will take approximately one hour. We thank you kindly for your cooperation and we hope that you will find participating in this assessment useful.”

Furthermore, it should be made clear that the informant’s participation is strictly voluntary and that (s)he can withdraw his/her permission for use of the data at any time, during or after the interview. Expectations about confidentiality and anonymity should be clarified. The interviewer(s) should, furthermore, ask the informant for permission to record the interview. The interviewer should not exert any pressure on the informant to give such permission and, if permission is not granted, the recording device should be left switched off and stowed away. Lastly, the interviewer(s) should make sure to give the informant the opportunity to pose any questions (s)he may have before commencing with the interview.

Conducting the interview

Provided permission is granted by the informant, interviews should be recorded whenever possible.

Furthermore, it is advisable that the interviewer(s) or a separate note taker create sufficiently detailed field notes to provide a summary of the interview, to enable regular reflection on the data thus far collected and to provide contextual detail to the interviews during the data analysis stage (e.g. observations regarding interview setting, presence of third parties during the interview). In order to maintain confidentiality and to reduce the risk of an interviewee feeling uncomfortable about discussing certain topics, we strongly recommend that during an interview no other people are present in the room than the informant(s), the interviewer(s), the note taker and, if relevant, a translator. The total number of people present in the room should be kept to a minimum. In particular other stakeholders in the assessment should not be present during the interview, even if they are members of the assessment working group, as this could lead to response bias wherein the interviewee may answer questions in a way that he or she considers agreeable to the other stakeholder present, or may avoid raising certain sensitive issues for fear of offending or reprisal.

The purpose of the interviews is to obtain information on the interactions between the HIV programme and the general health system by describing the level of integration of HIV programme functions with the general health system functions and eliciting the informant’s opinions on what determines the current status of interactions and how these interactions influence the performance of the HIV programme and of the health system. The type of information sought thus requires significant critical reflection on the part of the informant.

It is therefore important that the interviewer provides sufficient space for the informant to consider and formulate his/her answers, i.e. allows the informant enough time to elaborate his/her answers and, if necessary, clarifies the questions with the aid of the prompts provided. (Remember: a good interview is typically one in which fewer questions are asked but more detailed answers are given.) It is important that the interviewer keeps the focus clearly on issues of HIV programme and health system interaction rather than on a detailed description of the functioning of the health system or HIV programme itself. If the informant deviates too far from the topic of interest, the interviewer will need to steer the conversation carefully back on track. Also, if the answers are not sufficiently clear or specific the interviewer should probe further for clarification or ask for examples.

The interview guide has been designed in such a way that not all questions need be asked to all informants.

Rather, questions have been grouped into a series of thematic ‘modules’. It is recommended that per informant the interview focuses on only the 2 to 3 modules that are best aligned with the informant’s interests and areas of expertise. The order in which questions within a thematic module are posed may be altered compared to the interview guide, although it should be noted that questions have been arranged in the order that is most likely to follow the natural flow of a conversation. It is possible that answers to particular questions are already given in preceding questions. In that case, it is not necessary to repeat the question, although additional probing may serve to enrich the previously given answer.

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At the close of each interview, the informant should be asked whether (s)he has any remaining questions regarding the assessment process and/or her/his contribution to it. It can also be helpful to ask the informant whether (s)he can recommend any other informants for the assessment (i.e. ‘snowball sampling’).

Interviewer checklist

• Interview guide, including interview summary sheet

• Latest, updated versions of Diagrams 1-6

• Recording device with spare batteries⁵

• Notebook and pens/pencils

• If applicable: consent form

Phase 3: Data processing after the interview

At the end of every interview day or, when possible, after each interview the international lead expert and national consultant should discuss each interview and prepare a brief summary note (or elaborate the notes taken during the interview. See Annex 4). These discussions and notes will help identify areas that need further clarification in subsequent interviews with other key informants and provide an ‘organic’ overview of the main findings as they emerge.

If interviews have been recorded, recordings should be transcribed as soon as possible after the interview.

This is preferably done verbatim. As transcription can be a very time-consuming process, a professional transcription agency, preferably one familiar with medical and health systems terminology, can be used to do this. If, however, due to time and/or budget constraints verbatim transcription is not feasible, then the audio recordings should be used to create a set of reasonably detailed interview notes (or to elaborate the notes taken during the interview), whereby care should be taken not to impose any undue bias on what data is or is not captured in these notes. To preserve anonymity identifiers such as names or job titles should be removed from audio recordings and transcripts if these are shared with external parties. In that case, a separate record should be maintained to link back the files to individual respondents and this record should be kept confidential. Alternatively, the contract with the transcription agency should explicitly state the need to maintain informant anonymity. If interviews were conducted in a language other than English, transcripts and interview notes should be translated into English.

Phase 4: Data analysis

If possible, analysis should be done using the full, verbatim interview transcripts. However, if such transcripts are not available, the analysis should be based on the detailed interview notes. Due to the rapid nature of the assessment, a so-called ‘framework approach’ is best suited to the analysis. This approach uses an analytical framework that is derived from the a priori determined assessment objectives and data collection tools, while allowing for the emergence of new themes from the data.⁶ Individual sections from the interview transcripts and notes are indexed using predetermined, as well as emerging, themes and sub-themes. A preliminary version of the analytical framework is presented in Figure 2. However, this framework should be further refined throughout the data analysis.

The indexing of data against the framework is preferably done using a Qualitative Analysis Software (QAS) package, such as Atlas, Ti or NVivo, as this allows for rapid, easy retrieval of data according to theme or sub-theme. These indexed sections of the transcripts are then used to compare and contrast findings across the different interviews. Through an iterative process, hypotheses on effects and potential causal pathways are generated, tested against the data, and subsequently refined or rejected.⁷Secondary data sources (e.g.

policy documents, programme evaluations) can be used to triangulate findings.

5 The interviewer should have familiarized himself/herself with operating the recording device beforehand, i.e. know how to turn it on/off, know how to pause recording if the interview is interrupted, check that volume settings are correct, etc.

6 Pope C, Mays N. Qualitative research in health care, 3rd edition. Oxford, Blackwell Publishing, 2006.

7 Note: The process of “hypothesis testing” in qualitative research is distinct from statistical hypothesis testing as no numerical values are assigned to this type of data. Instead, it refers to the development of a theory to explain a certain ‘qualitative’ observation and using the personal judgement of the researcher to assess whether the theory is sufficiently supported by the interview data.

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• Integrated planning of HRH needs

• Integrated trainings

• Pay-roll integration & incentives

• Integrated distribution channels

• Centralised procurement

• Shared storage space

• Integrated training of lab staff

• Sharing of laboratory space, equipment, reagents & consumables

• Integrated data collection systems

• Alignment of indicators

• Joint evaluations & reviews

Themes

1. Leadership &

Governance

2. Financing

3. Health workforce

4. Medicines &

Technology

7. Laboratory

Impacts

Context

• Inter- and intrasectoral coordination

• Involvement of nongovernmental

organizations and civil society organizations

• efficiency & accountability

• Needs-based resource allocation

• Timeliness of resource availability

• Financial management capacity

• Financial sustainability

• Availability and distribution of human resources for health

• Health care worker skills and competencies.

• Staff motivation

• Procurement and inventory management capacity

• Drug availability, continuity and quality

• Availability and quality of equipment, reagents and consumables

• Diagnostic capacity

• Data quality, timeliness and completeness

• Data analysis capacity (human resources and information, communication and technology)

• Monitoring and evaluation related workload

5. Information

6. Service delivery

Topics

a. Management and oversight b. Policy-making and planning c. Policies and strategies

a. Financing sources and mechanisms

b. Contracting

a. Human resources for health policies, planning and training b. Health worker payment systems

a. Procurement and supply systems

a. Laboratory services a. Monitoring and evaluation systems

a. Delivery of targeted services

Interactions/mechanisms

• Integrated oversight structures

• Cross-learning and joint capacity-building

• Integrated planning structures

• Coordinated planning of activities

• Inclusion in general health budget

• Integrated financial reporting

• Integrated provider payment mechanisms

• Integrated service delivery points

• Referral systems and continuum of care

• Access to health services

• Health service utilization

• Comprehensiveness of care

• Stigma and discrimination

16 Guide for rapid assessment of interactions between HIV programmes and health systems

Figure 2. Analytical framework (to be refined during analysis)

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Phase 5: Reporting

Based on the findings from the initial data analysis, the inputs from the steering committee, and the discussions from a synthesis and validation workshop, the lead expert, with assistance from the national consultant and the assessment working group, will prepare a first draft of the assessment report, following a pre-defined structure (see Annex 4). The draft report will be shared with WHO and the members of the Steering Committee for their input before it is finalized. The report will include the findings as well as the recommendations for action that emerged from the synthesis and validation workshop. The final report should be shared with all stakeholders, in particular those who participated in any stage of the assessment.

Interview guide

This interview guide is not designed for use as a rigidly structured questionnaire. Rather, it should be seen as a guidance document, which provides sample questions in each thematic area of interest and, as such, can be used in a relatively flexible manner. For most questions a list of prompts is provided. These lists do not aim to be comprehensive and other issues, not covered by the prompts, may come up in the discussion.

It is, furthermore, not necessary to use all prompts.

Questions and prompts should be carefully selected and prioritized for each informant based on his/her interests and area of expertise. New questions can be formulated as deemed relevant for the study but this should be done with caution, as interview time is limited. Question series that are considered particularly relevant at the district or service delivery (health facility level) are indicated with ** at the end of the heading.

These are found mainly in thematic modules 3, 4, 6 and 7.

Before the interview starts, the informant should be informed of the objectives of the assessment and expectations of confidentiality and anonymity should be discussed (see Phase 2). The informant must give his/her consent for audio (or video) recording of the interview before the recording device is turned on.

1. Leadership and governance

Please use Diagrams 1 and 2 showing the organizational and decision-making structures to discuss the extent of their integration. If necessary, adjust these.

1.1 Programme management and oversight

1.1.1 How, if at all, is the management and oversight of the HIV programme integrated into the management structures of the general health system?

Prompts:

• Role of multi-sectoral National AIDS Committee in relation to role of Ministry of Health

• Role of nongovernmental organizations, private sector and development partners

1.1.2 What factors have influenced the current level of integration of the management and oversight structures⁸?

Prompts:

• Strengths/weaknesses of Ministry of Health management and oversight structures

• Donor requirements/initiatives

• Different financing sources for HIV or financial management mechanisms

1.1.3 In your opinion, what are the main advantages and disadvantages of the current level of integration of the management structures?

Note: consider from perspective of the HIV programme AND from the health system perspective.

Prompts: Positive/negative effect on

8 This refers to the integration of management and oversight structures for the HIV programme into the structures of the general health system.

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• Coordination between Ministry of Health programmes on cross-cutting issues ownership of, and commitment to, HIV response

• Autonomy of Ministry of Health/National AIDS Control Programme (NAP) in decision making Effectiveness of decision making processes (bureaucracy)

• Transparency and accountability in health sector health system management capacity (skill building, numbers of personnel)

• Multi-stakeholder engagement and commitment

• Multisectoral involvement and coordination

1.1.4 What opportunities do you see to improve the balance between the aforementioned advantages and disadvantages?

1.2 Policy-making and planning

1.2.1 How, if at all, are the structures (e.g. committees, programme units, working groups, coordinating mechanisms) for policy-making and planning for the HIV programme integrated into the general health policy-making and planning structures and mechanisms?

Prompts:

• Role of National AIDS Committee and of National AIDS Control Programme, in relation to Ministry of Health

• Composition and role of Global Fund to fight AIDS, Tuberculosis and Malaria Country Coordination Mechanism

• Role of nongovernmental organizations and civil society organizations

1.2.2 What factors have influenced the current level of integration of the structures for policy-making and planning⁹?

Prompts:

• Strengths/weaknesses in existing policy-making and planning structures

• Need for multi-sectoral involvement

• Need for involvement of nongovernmental organizations and civil society organizations

• Donor requirements/initiatives

1.2.3 In your opinion, what are the main advantages and disadvantages of the current level of integration of the structures for policy-making and planning?

Prompts: Positive/negative effects on

• Harmonization and alignment of policy-making and planning processes

• Collaboration between programmes and/or departments

• Building leadership and management capacity across health sector

• Focus on HIV and competence with regard to HIV among those involved in policy-making and planning

• Involvement of stakeholders not otherwise involved in health policy-making and planning (e.g.

civil society organizations)

• Coordination of stakeholders involved in policy-making and planning

• Efficiency of policy making processes and planning (e.g. avoidance of duplication of activities (e.g. number of meetings) and impact on workload

1.3 Policies and strategies

1.3.1 What are the main policies, strategies/plans currently affecting the national response to HIV?

9 This refers to the integration of structures for policy-making and planning for the HIV programme into the general structures for health policy-making and planning.

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Prompts:

• Multi-sectoral HIV/AIDS strategy and plan

• Health sector HIV/AIDS strategy and plan

• National HIV policy

1.3.2 How, if at all, are these HIV policies and plans integrated into other health and development policies and strategic plans?

Prompts:

• Inclusion in national growth and development plans

• Inclusion in national health sector policies and strategies

• Inclusion in reproductive health, child health and tuberculosis strategies

1.3.3 What factors have influenced the current level of integration of HIV policies and plans into other health and development policies and plans?

Prompts:

• Political prioritization of HIV response

• Epidemiological factors (e.g. overlapping epidemics)

• Cultural and social attitudes towards PLHIV (e.g. stigma)

• Legal frameworks

• Donor requirements/initiatives (e.g. poverty reduction strategy paper, Millennium Development Goals)

• Existing working relationships between programmes

1.3.4 How, if at all, has the current level of integration of HIV policies and plans¹⁰ affected coverage of HIV services?

• Equity in access for vulnerable and at-risk populations

• Focus on a) prevention, b) treatment, c) impact mitigation

• Coverage of particular services (e.g. prevention of mother-to-child transmission by integration into reproductive health policies, HIV testing through policies for provider-initiated testing) 1.3.5 How, if at all, has the current level of integration of HIV policies and plans¹⁰affected the quality of

HIV services?

• Care continuum for PLHIV (by more inclusive policies/plans)

• Emphasis on rights-based approach to HIV and health services

• Implementation of health and safety policies (e.g. use of gloves, disposable syringes)

1.3.6 How, if at all, has the current level of integration of HIV policies and plans affected sustainability of HIV services?

• Government commitment and ownership

• Dependence on financial and technical support from donors and nongovernmental organizations

1.3.7 In your opinion, what are the main advantages and disadvantages of the current level of integration of HIV policies and plans?

• Awareness of HIV policies and strategies with other (non-HIV) stakeholders

• Multi-sectoral involvement in, and ownership of, the HIV response

10This refers to the integration of HIV policies and plans into other health and development policies and plans.

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• Clearly defined ownership and responsibility for development of HIV policies and plans

• Ability to build consensus on HIV-related policies among stakeholders

Note: Answer may include both actual opportunities and ideal scenarios (i.e. preferences)

2. Health financing

Please use generic Diagram 3 on HIV and health sector financing to discuss the extent of integration of financing sources and mechanisms. If necessary, adjust the diagram.

2.1 Financing sources and financial management mechanisms for the HIV programme in the Ministry of Health

2.1.1 Is the budget for the Ministry of Health HIV programme integrated into other budget lines or does the HIV programme have a specific HIV budget line?

Questions 2.1.2 to 2.1.5 are relevant in countries that receive external financial support (e.g. GFATM or other donor support)

2.1.2 How is the management of the external funding sources for the HIV programme integrated into the general financial management mechanisms within the health sector?

Prompts:

• Extent of off-budget (donor) support and its integration in government financial management mechanisms

2.1.3 What factors have influenced the current level of integration¹¹? Prompts:

• Strengths/weaknesses in financial management mechanisms

• Donor requirements/initiatives (e.g. joint financing mechanisms)

2.1.4 In your opinion, what are the main advantages and disadvantages of the current level of integration?

• Alignment between resource allocation and health needs

• Government ownership of HIV response

• Potential for financing health system strengthening or cross-cutting activities

• Availability and predictability of funds for HIV

• Availability and predictability of funds for other health priorities

• Building of financial management capacity

• Financial accountability

• Efficiency of financial management for HIV services (e.g. high transaction cost of parallel systems)

• “Crowding out” effect of donor funds on public resources allocation for HIV (decreased public resource availability for HIV services by shifting to other health priorities)

• Resentment or envy between health programmes/departments over resources

• Distortion of routine revenue collection systems (e.g. if HIV services are free at point of delivery but non-HIV services are not)

11 This refers to the integration of the external financing sources for the HIV programme into the general financial management mechanisms.

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2.2 Mechanisms for provider-payment

2.2.1 Which HIV services (if any) are part of the national a) minimum/b) optional service package to be provided by national health services?

Prompts:

• HIV testing for antenatal care, tuberculosis, sexually transmitted infection patients

• Antiretroviral treatment

• CD4 count

• Tuberculosis diagnosis

2.2.2 Is this minimum/optional service package mandatory for private health services?

• Private for-profit

• Private not-for-profit

2.2.3 How, if at all, is the payment for HIV-related care and treatment services integrated into the payment systems for health services?

Prompts:

• Extent of inclusion of HIV-related services in government-subsidized service packages (see question 2.2.1 to 2.2.2)

• Extent of inclusion of HIV-related services in health insurance benefit package

• Exemption of VCT, ART and related services (e.g. treatment monitoring) from user fees

• Extent of requirement for household contributions (out-of-pocket payments; cost-sharing;

informal payments) compared to other non-HIV related health services

• Differences between public and private sector

• Differences between different groups of service users (e.g. pregnant women)

2.2.4 What factors prevent and what factors can facilitate further integration of payment systems¹²? Prompts:

• Availability of national resources in the public sector

• Government commitment to international declarations and targets (e.g. UN declaration to universal access)

• Donor initiatives (e.g. drug donation or subsidy programmes)

• Extent of health insurance coverage, including community health insurance

• Extent of the informal sector (i.e. workers without employer benefits)

• Role of public—private partnerships

2.2.5 How, if at all, has the current level of integration of the payment systems affected the coverage of HIV services?

Prompts:

• Increased coverage due to low cost for people living with HIV

• Limited coverage due to high cost for people living with HIV

• Limited coverage due to difficulties for providers to recover cost (insufficient cost coverage by government/insurance/users)

• Equitability of access to services

• Increased coverage due to de-stigmatization of HIV services if payment is integrated in usual payment systems (or opposite if not integrated)

2.2.6 How, if at all, has the current level of integration of the payment systems affected the quality of HIV services?

Prompts:

• Quality difference between services in the public vs. private sector (e.g. access to advanced diagnostics for treatment monitoring)

12 This refers to the integration of the payment systems for HIV-related services into the payment systems for general health services.

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Guide for rapid assessment of interactions between HIV programmes and health systems

Guide for rapid assessment of

interactions between HIV programmes and health systems

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Guide for rapid assessment of interactions between HIV programmes and health

systems

Contents

Acknowledgements

Introduction

Figure 1. Conceptual framework for rapid assessment

HIV incidence and mortality Other health outcomes

Health system

HIV programme

Degree of integration and interaction of health system functions and HIV programme

Context

Epidemiology

Politics

Legal frameworks

Economic factors

Sociocultural factors

HIV programme performance HIV services

Health system performance General health services

Conceptual framework

Purpose of the assessment

Overview of rapid assessment methodology

Assessment process

Definitions

Rapid assessment instrument

Table 1. Diagrams to be prepared before interviewing informants

Context

Figure 2. Analytical framework (to be refined during analysis)

Interview guide